Difference between revisions of "Symptoms"

From Patient Determinants
Jump to: navigation, search
Line 84: Line 84:
 
==[[Mental Health]]==
 
==[[Mental Health]]==
  
−
==[[General/Other]]==  
+
==[[General/Other]]==
−
 
+
−
==[[Functional Limitations]]==
+
−
 
+
−
===Hearing===
+
−
* Difficulty Hearing in some environments
+
−
* Absence of useful hearing
+
−
===Walking===
+
−
* Some difficulty without devices
+
−
* Some difficulty with devices
+
−
* Requires wheel chair or devices
+
−
===Sleeping===
+
−
* Trouble falling asleep
+
−
* Trouble staying asleep
+
−
===Understanding (by care giver)===
+
−
* Misses part of message
+
−
* Limited understanding
+
−
* Unable to understand
+
−
===Communication (by care giver)===
+
−
* Some Difficulty expressing needs and ideas
+
−
* Frequent difficulty expressing needs and ideas
+
−
* Very difficult to understand
+
−
===Vision===
+
−
* Large objects and print only
+
−
* Object identification questionable
+
−
===Standing===
+
−
* Need device assistance
+
−
* Unable with device assistance
+
−
===Grip===
+
−
* Limited 
+
−
* Absent
+
−
===Breathing===
+
−
* Severe shortness of breath at rest
+
−
* Mild shortness of breath at rest
+
−
* Shortness of breath with minimal exertion
+
−
* Shortness of breath with moderate exertion
+
−
* SOB when climbing stairs
+
−
* Uses ventilator
+
−
===Mobility Endurance===
+
−
* Walk or wheel chair 50 feet
+
−
* Can't do it
+
−
* Only with rest
+
−
===Sitting Endurance===
+
−
* Tolerate sitting for 15 minutes
+
−
* Can't do it
+
−
* Only with support
+
−
===Primary Mobility Mode===
+
−
* Cane/crutch
+
−
* Walker
+
−
* Orthotics/prosthetics
+
−
* Wheelchair/scooter full time
+
−
* Wheelchair/scooter part time
+
−
* No movement from bed
+
−
 
+
−
==Activities of Daily Living - Limitation==
+
−
* Bathing and showering
+
−
* Shower/bathe requires transfer
+
−
* Wash face, hands, chest, arms
+
−
* Dressing (Upper body, Lower body, put on/take off socks and shoes)
+
−
* Self-feeding (not including chewing or swallowing)
+
−
* Movement from one place to another to perform activities
+
−
* Personal hygiene and grooming
+
−
* Toilet hygiene
+
−
* Toilet transfer - safely on an off
+
−
===Mobility===
+
−
* Lying to sitting on side of bed
+
−
* Sit to stand
+
−
* Chair/Bed to wheelchair
+
−
* Sit to lying flat on bed
+
−
* Roll left and right
+
−
* Bend and pick up objects
+
−
===Transportation Mobility===
+
−
* Unable to car transfer
+
−
* Wheel chair lift only
+
−
+
−
==Instrumental Activities of Daily Living (IADLS)- Limitation==
+
−
* Telephone (Answer phone, place calls
+
−
* Take medications as prescribed (oral, inhalants/mists, injectable)
+
−
* Make light meal
+
−
* Wipe down surface
+
−
* Light shopping
+
−
* Laundry
+
−
* Use public transportation
+
−
* Mange money and pay bills
+
−
* Use computer
+
−
* Use a smart phone
+
−
===Instrumental Activities of Daily Living (IADLS)- Other===
+
−
* Care of others (Family members)
+
−
* Care of pets
+
−
* Child rearing
+
−
* Maintain social relationships
+
−
* Community Mobility
+
−
* Maintain Financial Management
+
−
* Maintain Health Management
+
−
* Maintain Home Management
+
−
* Meal preparation and cleanup
+
−
* Maintain Religious Observances
+
−
* Maintain safety procedures and emergency responses
+
−
* Shopping
+

Revision as of 10:26, 9 June 2015

Patient reported symptoms can affect a patient's overall health and well-being. The symptoms are reported by the patient with the Symptom Assessment, which is a component of the Well-Being Assessment. It will be updated regularly via the well-being status. Symptoms are typically addressed by assigning Care Goals and interventions and activities in the Care Plan.

Symptom Assessment

Pain or Discomfort

General

  • Muscles cramps or spasms (painful)
  • Tenderness to touch
  • Swelling
  • Bruising or discoloration
  • Stiffness or decreased movement
  • Body aches
  • Itching or burning

Head area

  • Sore throat
  • Headache
  • Enlarged or swollen glands
  • Ear ache
  • Mouth, teeth or gums

Stomach Area

  • stomach ache
  • Menstrual cramps
  • Bloating or fullness
  • Pressure or fullness
  • Gas

Chest Area

  • Chest Pain
  • Feeling heart pound or race
  • Heart palpitations
  • Indigestion
  • Heart burn
  • Shortness of breath
  • Lung congestion

Other

  • Joints
  • Back
  • Arms or legs
  • Muscles other
  • Other

Sleep & Fatigue

  • Night sweats
  • Trouble sleeping
  • Sleepy all the time
  • Unusual Fatigue

Visual Symptoms

  • Skin ulcer
  • Skin rash
  • Lump or bulge
  • Swelling
  • Bleeding or wound
  • Drainage or pus
  • Vaginal discharge
  • Visible deformity

Cold and Flu-like

  • Fever
  • Head ache
  • Aches and pains
  • Fatigue and weakness
  • Extreme exhaustion
  • Stuffy nose
  • Sneezing
  • High temperature or fever (warm to touch)
  • Cough - productive
  • Cough - dry
  • Congested lungs

Abnormal Occurrences

  • Numbness or tingling
  • Dizziness
  • Cough
  • Fainting spells
  • Nausea or vomiting
  • Nasal Congestion
  • Abnormal bowel movements (Change in bowel habits, Diarrhea, constipation, loose bowels)
  • Abnormal urination (frequent urge to urinate, cloudy urine with strong order, pain during urination, frequent bladder infections)
  • Weight - unusual weigh gain or loss
  • Hair loss - unexpected

Mental Health

General/Other